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Guard & Reserve

Name

First Name

Last Name

Personal Email

Rank/Paygrade

Total Years in Service

Years of Active-Duty Service

Personal Phone

Country

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Branch of Service

Component

Status

Status (cont.)

Use this text field if 'other' was chosen.

Unit Assigned

Command, State, Installation, Unit

Immediate Commander's Info

Last Name, First Name, Rank (E1-E9, O1-O10, W1-W5), Email, Phone (comm/cell, not DSN)

Next Level Commander's Info

Last Name, First Name, Rank (E1-E9, O1-O10, W1-W5), Email, Phone (comm/cell, not DSN)

Line of Duty Determination Status

Disability Evaluation System Progress

VA Disability Rating Status

VA Disability Rating

0-100%

Summary of Situation

500 words or less.

Assistance Requested

500 words or less.

UCMJ and/or Disciplinary Action

UCMJ and/or Disciplinary Action (cont.)

If 'yes' was chosen, provide an explanation using 500 words or less.

Pending Suspense(s)/Deadline(s)

100 words or less.

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